Common Back Problems in the Mature Athlete

Mark E. Lavallee, MD, CSCS, FACSM

Director, WellSpan York Sports Medicine Fellowship

Head Team Physician, Gettysburg College

Chairman, USA Weightlifting Sports Medicine Society

Medical Director, IWF Masters World Championships

Feb 1st 2017

Conflicts of Interests

• I have no conflicts of interest in regards of this topic.

• I have no financial relationships to divulge that would impact the bias nature of this lecture other than:• Grant Recipient- U.S. Conference of Blind Chiropractic Physicians• Paid retaining fee for medical witness for Rosen, Rosen, Rosen, O’Sullivan

workers compensation lawyers specializing in “Slip and Fall.”• Paid Co-Spokesmodel with Shaquille O’Neal for ICYHOT back patches

• No nursing home patients were HARMED during the making of this lecture

• Patients mentioned in this lecture have given permission to use their likeness for educational purposes.

Objectives

• Incidence of Back in Older Patients vs. Mature Athletes

• Getting the “History”

• Classification of Back Pain (Acute vs. Chronic)

• Region of Pain • Cervical• Thoracolumbar• Sacral

• Imaging / Diagnostics of Spine

• Treatment Options

• Return to Play

• Special Considerations for Mature Athlete

Incidence of Back Pain in Older Patients vs. Mature Athletes

Getting the History – It’s CRUCIAL

• Chief Complaint• Pt’s own words

• Insight : How does pt perceive pain

• Ask several times, several different ways

• Location

• Onset

• Duration

• Quality

• Exacerbation

• Palliation

History

• Location • Be specific ( used for comparison at follow-up visits)

• Midline vs. paraspinal

• Thoracolumbar vs lumbar vs sacral

• Buttock vs flank vs SI

• Right vs Left vs Diffuse

• Referred to…• SI, gluteal / buttock, post thigh

• Groin, lateral hip

History

• Onset • Acute – specific event?

• Subacute –Delayed onset• Following unusual activity

• “woke up with it”

• Chronic• Previous history

History

• Duration• “All the time”

• “Some of the time”

• Quality• Dull, deep, sharp, shooting, electricity

• Gripping, Tearing, Numb, Tingling

• Use Pt’s own words• Confidence you’re listening

• Speak pt’s language

History

• Exacerbation• What makes it worse

• Be specific – document

• Palliation• What makes it better

• Most patients with REAL pathology can find some palliation / relief

• Standing, laying flat, feet up, fetal position…

• Beware: no relief, pain all the time

History

• Past History - Tx thus far• Meds

• NSAIDS (with dosages), muscle relaxers, narcs, neurontin

• P.T.• How long? Results? Where?

• Chiropractor- How many visits (<3 = GOOD)

• Injections – location, type, when???

• Surgery

• Obtain letters, office notes, • X-ray reports, PT reports,

• injection / surgical reports

History

• Past History • Beware:

• Vague symptoms

• Uncertainty RE: past Tx

• Pain out of proportion

• Multiple Narcotic “allergies”

• Requesting Medical MJ or CBD oil,

• Social Hx• ETOH, Drugs

• Tobacco – direct correlation with back pain• Smoking cessation: Pt actively interested in own health

History- it will give you the ANSWER

• 85% Dx by Hx alone• Hx points toward Dx

• PE corroborates Hx

• Studies confirm Dx

• Goal• Identify Real vs. perceived problem

• Back pt’s will talk all day – stay focused

• Athletes generally more reliable

• Back Pain vs leg pain (nerve irritation)

Physical Exam of Spine in the Mature Athlete

• Due to time constraints will GLOSS OVER this subject

• Suggest you return and study the next 6 slides at later time

Physical Examination Inspection

• Patient as whole then focus spine

• Adequate exposure

• Standing posture• kyphosis, lordosis, scoliosis, list

• head position, shoulder level, pelvic tilt

• Skin• bruising, swelling, deformity, mass

Physical Examination Range of Motion

• Relative range important (individual variance)• Pushing up on thighs

• Hamstring tightness

• Squat• ROM lower extremities, hips

• Strength/ Balance (mini neuro exam)

Physical Examination Gait

• Arise from chair / exam table

• Reciprocal• Limp• Shuffling• Posture

• Heel walk

• Toe Walk

• NOTE: gait speed is single greatest determinant of quality of life in octogenarians.

Physical Examination Palpation

• Start with non-painful areas first• gains trust

• allows examination of other areas

• Identify pain generator• Point tenderness vs. diffuse

• “One Finger” test

• Anatomic Landmarks• spinous processes, paraspinal

• PSIS, SI joint, sciatic notch• deep posterior thigh, ischial tuberosity

Physical Examination Neurologic exam

• Motor Exam• L1-2 Hip Flexors

• L3 Quadriceps extension

• L4 Foot dorsiflexion/ Quads

• L5 Great toe extension/ Foot eversion

• S1 Foot plantarflexion/ Knee flexion

Physical Examination Neurologic Exam

• Sensory Exam• C4 Clavicles

• T4 Nipples

• T10 Umbilicus

• L1 Inguinal

• L3 Lateral leg

• L4 Medial leg

• L5 Dorsum foot

• S1 Lateral/ Sole foot

• S2-4 Perianal

Physical Examination Neurologic Exam

• Reflexes• Lower motor neurons (DTR’s)

• L4 Knee

• S1 Ankle

• Upper motor neurons• Babinski

• Clonus

• Provocative testing• Straight leg raises

• Femoral nerve stretch test

LeSeague’s Test

SLR

Causes of Cervical Pain in Mature Athletes

• ACUTE• Myofascial/Somatic Dysfunction

• Transient Brachioplexapathy (i.e. Stingers)

• Discogenic

• Stenosis (Canal vs. Neuroforaminal)

• Fracture (Osteoporotic vs. Trauma)

• Myocardial Ischemia/Infarction

• Infection• Disciitis, Meningitis

• CHRONIC• Spondylarthopathies

• Facet Arthritis

• Degenerative Disc Disease

• Spinal Stenosis

• Osteoporosis

• First Rib Fractures

• Autoimmune-Lupus, RA, PMR

• Tumor• Pancoast

ACUTE Cause of Cervical Pain in Mature Athletes

• Myofascial/Somatic Dysfunction• Levator Scapulae – “stiff neck”• Scalenes – “ Deep neck pain”• Semispinalis Cervicalis/Capitis “Ache into

Head, posterior neck pain”• Trapezius- “Coat Hanger” distribution

• Discogenic• Stenosis (Canal vs. Neuroforaminal)• Fracture (Osteoporotic vs. Trauma)• Pancreatitis• Infection

• Disciitis, meningitis, Lymes, pneumonia

CHRONIC Causes of Cervical Pain in Mature Athletes

• Spondylarthopathies

• Facet Arthritis

• Degenerative Disc Disease

• Spinal Stenosis

• Osteoporosis

• First Rib Fractures

• Autoimmune-Lupus, RA, PMR

• Fibromyalgia

• Tumor• Pancoast, lung cancer

Causes of Thoracolumbar Pain in Mature Athletes

• ACUTE CAUSES• Myofascial• Somatic Dysfunction• Discogenic• Stenosis (Canal vs. Neuroforaminal)• Fracture (Osteoporotic vs. Trauma)• Pancreatitis• Infection

• Disciitis, meningitis, Lymes, Pneumonia,

• Spontaneous Pneumothorax• Aortic Aneursym

• CHRONIC CAUSES• Spondylarthopathies• Facet Arthritis• Degenerative Disc Disease• Spinal Stenosis• Osteoporosis• Autoimmune

• Lupus, RA, Ankylosing Spondylitis, PMR, Myositis

• Fibromyalgia• Lyme’s Disease• Tumor

• Primary-Multiple Myeloma• Metastatic-Prostate, Renal Cell, Breast

CA

ACUTE Causes of Thoracolumbar Pain

• Myofascial • Quadratus Lumborum• Iliopsoas

• Somatic Dysfunction • Rhomboid Dysfxn, Posterior Ribs

• Discogenic• Stenosis (Canal vs. Neuroforaminal)• Vertebral Fracture (Osteoporotic)• Pancreatitis• Infection

• Disciitis, meningitis, pneumonia

• Spontaneous Pneumothorax• Aortic Aneursym

CHRONIC Causes of Thoracolumbar Pain

• Spondylarthopathies

• Facet Arthritis

• Degenerative Disc Disease

• Spinal Stenosis

• Osteoporosis

• Autoimmune• Lupus, RA, Ankylosing Spondylitis

• Lyme’s Disease

• Fibromyalgia

• Tumor• Primary-Multiple Myeloma• Metastatic-Prostate, Renal Cell, Breast CA

Causes of Sacral Pain in Mature Athletes

• ACUTE• Somatic/Sacral Dysfunction

• Sciatica (Fem Nerve Irritation)

• Endometriosis

• Occult /Coccyx fracture (i.e. Fall)

• CHRONIC• SI Joint arthritis

• SI Joint instability

• Sacral Stress fracture

• Leg Length Discrepancy

• Metastatic fracture• Prostate, RCC, Ovarian, Mult Myeloma

• Hip Osteoarthritis

• Lyme’s Disease

• Autoimmune- Lupus, RA, AS

ACUTE causes of Sacral pain in Mature Athletes

• Somatic/Sacral Dysfunction• Gluteal Medius –”Lumbago of Back”

• Gluteal Minius – “Pseudo-Sciatica”

• Piriformis – “ Post. Hip Weakness”

• Sciatica (Fem Nerve Irritation)

• Endometriosis

• Occult /Coccyx fracture (i.e. Fall)

CHRONIC Causes of Sacral Pain in Mature Athletes

• SI Joint arthritis

• SI Joint instability

• Sacral Stress fracture

• Leg Length Discrepancy

• Metastatic fracture• Prostate, RCC, Ovarian, Mult

Myeloma

• Hip Osteoarthritis

• Lyme’s Disease

• Autoimmune- Lupus, RA, AS

Imaging of the Spine

• Plain Radiography• AP and Lateral most helpful• Oblique view

• Limited value in Thoracic• Most helpful for:

• Stenosis in Cervical/Lumbar• Spondyloarthropathies “Scotty Dog” Sign in Lumbar

• Improves sensitivity by 20% over top just AP/LAT• Excessively more radiation

• Flexion/ Extension Views• If Instability suspected in Cervical or Lumbar• Spasm may mask instability (i.e. “lithesis”)• Re-evaluate alignment

Imaging of the Spine

• Computed Tomography• Allows visualization of spatial anatomy

• Bone seen best

• Confirmatory test - not exploratory

• routine CT not useful or cost effective

• Slice thickness may miss pathology

• MRI• Gold standard for soft tissue detail

• No radiation

• Built-in bone scan (T2)

• Helps show inflammation

Imaging & Diagnostics of the Spine

• Bone Scan• Sensitive but not specific• Increased uptake = bone turn-over• Helpful for stress fractures, metastatic disease

• SPECT Scan• Suspected lesion not seen on XR• Not responding to treatment 6-8 weeks• Special Bone Scan that cones in to lumbar segments• Used primarily to stage Spondys as acute vs. chronic• May help distinguish healing potential

• chance for healing = hot scan

• established non-union = cold

• Discography• Degenerative disc, limited use, very painful• May not correlate

• EMG/NCS• Helpful in determine peripheral vs spinal origin of neuropathic pain or dysfunction

Fire Scan v. MRI

• “FIRE SCAN” combined SPECT and CT• Combined modalities • Increased radiation• Improved imagine• Takes longer (two separate tests)

• MRI• Suspected lesion not seen on XR• Considering a stress fracture vs. an occult fracture• SPECT scan not available• Cost• No Radiation

Treatment Options - ACUTE

• ACUTE• Soft tissue

• Manipulation (DO/Chiro/LMT/DPT)

• Dry Needling

• ICE

• Stretching / Home Exercise Program

• Medications• NSAIDs

• Prednisone

• Muscle Relaxers

• Transdermal (patch vs. Lipoderm)

Treatment Options - CHRONIC

• Formal Physical Therapy• Myofascial Release• Electrical Stim (TENS unit)• Back School

• Core Strengthening exercise

• Weight loss – Obesity is EPIDEMIC, do not be afraid to address it!!

• Mindfulness/Biofeedback

• Acupuncture

• Maximize Medication Control • Tiered approach

• Injections (facet, trigger, IM, epidural, facet, prolotherapy, etc.)

• Ablative (electrodiagnostic, blocks, etc)

• Surgery (decompression/ORIF) – LAST RESORT

• AVOID DAILY USE OF NARCOTICS

Dangers of Opioid Prescribing (Goldilocks Syndrome)

• Giving too little• Pain is undertreated• Leads to misuse: hoarding, taking more than prescribed, using

other drugs or meds

• Giving too much• Contributing to abuse• Contributing to diversion• Excessive side effects

• Giving just the right amount• May mask pain and contribute to re-injury• May make the pt uninterested in other therapy

• TOLERANCE IS THE LONG TERM USE EFFECT, #1 reason patients start seeking non-prescription narcotics

Millions of Prescriptions (US Data)

http://www.webmd.com/news/20110420/the-10-most-prescribed-drugs Accessed 1/1/14

Dangers of Opioids©

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6043a4.htm?s_cid=mm6043a4_w

Return to Participation for Mature Athletes

• Light training as pain allows

• Increase activity based on:• severity of injury

• athlete’s compliance

• specific sport

• past medical history

• physician comfort level

• Return to FULL activity • once pain controlled

• ROM and Strength normal

Special Considerations in Mature Athletes

• Most are familiar with back pain as both an athlete and an older person, take compliant seriously. Treat effectively. Help them return to activity

• Keep your Differential LARGE in Mature Athletes c/o Back Pain• Cervical – First Rib fx, Myocardial Ischemia• Thoracolumbar – Ankylosing Spondylitis, Lymes, Metastatic tumor, AAA, • Sacral – Endometriosis, Lymes.

• Keep your Mature athlete active, mobile and engaged in their sport if at all possible

• Avoid NARCOTICS in treatment of Chronic and most Acute cases of Back pain

References

• PF Langer, “Considerations in treating physically active older adults and aging athletes,” Clin Podiatr Med Surg. 2015 Apr;32(2):253-60.

• Quatman C, Yu JS, “ The Aging Athlete, Part two, Boomeritis of the Upper Extremity,” AJR Am J Roentgenol. 2012 Sep;199(3):W307-21.

• Quatman C, Yu JS, “ The Aging Athlete, Part one, Boomeritis of the Lower Extremity,” AJR Am J Roentgenol. 2012 Sep;199(3):W322-31.

• Arlis-Maypr S,”Medical considerations for the Masters Athlete,” Conn Med. 2012 Sep;76(8):455-9.

• Borg-Stein J, Elson L, Brand E, “The Aging Spine in Sports,” Clin Sports Med. 2012 Jul;31(3):473-86.